HIPAA Notice of Privacy Practices by ErMKtl


									                                      HIPAA Notice of Privacy Practices

                         PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out
treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also
describes your rights to access and control your protected health information. “Protected health information” is information
about you, including demographic information, that may identify you and that relates to your past, present or future physical
or mental health or condition and related health care services.

1. Uses and Disclosures of Protected Health Information
Uses and Disclosures of Protected Health Information
Your PHI may be used and disclosed by your therapist, our office staff, and others outside of our office that are involved in
your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the
operation of the physician’s practice, and any other use required by law.

Treatment: We will use and disclose your PHI to provide, coordinate, or manage your health care with a third party. For
example, we would disclose your PHI, as necessary, to a home health agency that provides care to you. Your PHI may be
provided to a physician to whom you have been referred to ensure that the physician has the necessary information to
diagnose or treat you.

Payment: Your PHI will be used, as needed, to obtain payment for your health care services. For example, obtaining
approval for a hospital stay may require that your relevant PHI be disclosed to the health plan to obtain approval for the
hospital admission.

Healthcare Operations: We may use or disclose, as needed, your PHI in order to support the business activities of your
therapist’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities,
and training of medical/mental health professional students that see patients at our offices. In addition, we may use your
PHI, as necessary, to contact you to remind you of your appointment. We may use or disclose your PHI in the following
situations without your authorization. These situations include: as Required by Law; Public Health issues as required by
law; Communicable Diseases; Health Oversight; Abuse or Neglect; Food and Drug Administration requirements; Legal
Proceedings: Law Enforcement: Coroners, Funeral Directors, and Organ Donation: Research: Criminal Activity: Military
Activity and National Security; Workers’ Compensation; Inmates; Required Uses and Disclosures; Under the law we must
make disclosures to you and when required by the Secretary of the Department of Health and Human Services to
investigate or determine our compliance with the requirements of Section 164.500.

Other Permitted and Required Uses and Disclosures Will be made only with your consent, authorization or opportunity to
object unless required by law.

You may revoke this authorization, at any time, in writing, except to the extent that your therapist or our office has taken
an action in reliance on the use or disclosure indicated in the authorization.

Your rights
Following is a statement of your rights with respect to your PHI.

You have the right to inspect and copy your protected health information. Under federal law, however, you may not
inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a
civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits
access to protected health information.

You have the right to request a restriction of your PHI. This means you may ask us not to use or disclose any part of
your PHI for the purposes of treatment, payment or healthcare operations. You may also request that any part of your PHI
not be disclosed to family members or friends who may be involved in your care or for the notification purposes as described
in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the
restriction to apply.

Your therapist is not required to agree to a restriction that you may request. If therapist believes it is in your best interest to
permit use and disclosure of your protected health information, your PHI will not be restricted. You then have the right to
use another Healthcare Professional.

                                     HIPAA Notice of Privacy Practices
You have the right to request to receive confidential communications from us by alternative means or at an
alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have
agreed to accept this notice alternatively i.e. electronically.

You may have the right to have your health care provider amend your PHI. If we deny your request for amendment,
you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will
provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health

I reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to
object or withdraw as provided in this notice.

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been
violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate
against you for filing a complaint.

This notice was published and becomes effective on/or before April 14, 2003.

I am required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy
practices with respect to PHI. If you have any objections to this form, please ask to speak with me at my main number.

The following are a list of exclusions to the Health Information Portability Act that allow for a more efficient use of your time
and the provider’s time. Please initial the specific exclusions you would agree to. If you do not want to authorize permission
for any one or all simply leave blank:

    1.   ______ I give my permission to allow John W. (Bill) Murphy, LMFT (or office staff) to call and remind me by phone
         of my appointments. This permission extends to allowing a reminder about my next appointment to be left on my
         answering machine or voice mail.
    2.   ______ I give my permission to use my first name in the waiting room when calling me back to my session.
    3.   ______ I give my permission to send or receive email from John W. (Bill) Murphy, LMFT (or office staff) as a
         reminder of appointments or in response to an email sent by you the client. I understand that information
         transferred via the Internet in this manner is not a completely secure form of communication. My email address

    4.   ______ I give my permission to fax any essential psychological information to my personal physician,
          (Dr. ____________________________________Fax_______________________), HMO, insurance provider,
         hospital, attorney or other medical provider involved in my treatment.
         Note: no personal information will be faxed to anyone without your signed (separate and apart from this document)
         authorization to do so.

Signature below is only acknowledgement that you have received this Notice of our Privacy Practices:

Print Name: __________________________________________

Signature: ____________________________________________



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